Provider Demographics
NPI:1215356779
Name:MARY B RIEDEL
Entity Type:Organization
Organization Name:MARY B RIEDEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIEDEL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:608-799-1208
Mailing Address - Street 1:317 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-8614
Mailing Address - Country:US
Mailing Address - Phone:608-799-1208
Mailing Address - Fax:
Practice Address - Street 1:115 5TH AVE S
Practice Address - Street 2:SUITE 301
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-9200
Practice Address - Country:US
Practice Address - Phone:608-799-1208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4671-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100029060Medicaid